What Happens to Disinhibited Social Engagement Disorder Over Time?

Disinhibited social engagement disorder (DSED) is one of the most intriguing syndromes in child and adolescent psychiatry but also one of the least understood. We know little about its developmental course in different groups of children, so I was delighted to see the incisive longitudinal work from the Bucharest Early Intervention Study by Guyon-Harris and colleagues.1 My own interest in DSED was sparked back in the early 1990s, when a travel bug had taken me to Guatemala and I had found a job in an orphanage. I was also the family doctor to the surrounding villages, in which children were considerably more materially deprived than their peers in the orphanage who had three meals a day, chlorinated running water, and a reliable school. What the orphanage children did not have was family care-instead they experienced rotating shifts of carers, many of whom were travelers like me, some only there for one or two weeks. Prior to my trip, a senior child psychiatrist had armed me with Bowlby's Attachment and Loss2 and a photocopy of the ICD-10 classification of "disinhibited attachment disorder." My dual role in the orphanage soon made it obvious that the social behavior of many of the institutionalized children was grossly different from that of their family-reared peers. Strangers could not walk into the orphanage until they had peeled off the hands of the small children who had crowded them. In contrast, children in local family homes peeked out from behind their mother's skirts-just as John Bowlby had said they would. Indiscriminate behavior was adaptive in the orphanage setting, because otherwise emotionally neglected children received bursts of attunement from whichever carer was available. The same indiscriminate behavior was, however, highly maladaptive outside the orphanage setting, as children would wander off without checking back and put themselves in danger.